Healthcare Provider Details

I. General information

NPI: 1013025097
Provider Name (Legal Business Name): DIANE JORDAN-WAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 N 6TH ST
TERRE HAUTE IN
47804-1037
US

IV. Provider business mailing address

221 S 6TH ST
TERRE HAUTE IN
47807-4214
US

V. Phone/Fax

Practice location:
  • Phone: 812-232-0564
  • Fax: 812-235-3330
Mailing address:
  • Phone: 812-232-0564
  • Fax: 812-235-3330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number01056292A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number36106006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: